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Abstract

Background

The objective of this review is to identify and critically evaluate the published
literature on emergency medicine (EM) training programs in resource-limited health-care
settings in order to provide insight for developing EM training programs in such health
systems.

Methods

A literature search was conducted up to the end of April 2011 using MEDLINE, EMBASE,
The Cochrane Library, EBM Reviews, Healthstar and Web of Science databases, using
the following search terms: Emergency Medicine, Emergency Medicine Services, Education
Training Residency Programs, Emergency Medical Systems and Medical Education, without
limitation to income countries as outlined in the World Bank World Trade Indicators
classification 2009-2010 (World Trade Indicators Country Classification by Region
and Income, July 2009-July 2010). As the intent of the review was to identify and
critically evaluate the literature readily available (published) to LMICs developing
EM programs, the gray literature was not searched.

Results

The search yielded 16 articles that met the final inclusion criteria. As the majority
of articles provide a narrative description of the processes and building blocks used
in developing the residency programs reported, we present our results in narrative
format. By providing a summary of the lessons learned to date, we hope to provide
a useful starting point for other resource-limited settings interested in establishing
emergency medicine specialty training programs and hope to encourage further information
exchange on this matter.

Conclusions

The results of the review indicate that EM training is in its infancy in resource-constrained
health-care systems. There are few detailed reports of these programs successes and
limitations, including efforts to optimize graduate retention. Despite the paucity
of currently published data on the development of EM residency training programs in
these settings, this review demonstrates the need for encouraging further information
exchange to aid in such efforts, and the authors make specific recommendations to
help guide future authors on reporting on such efforts.

Keywords:

Emergency medicine; Residency; Training programs; Education

Background

Emergency medicine (EM) is a relatively new specialty around the world, having been
officially recognized in both Europe and North America only in the latter half of
the twentieth century. To this day, emergency departments (EDs) in many countries
are not staffed with specialists with specific training in the discipline, but rather
with rotating off-service staff physicians or with residents and interns. This is
particularly true in resource-limited settings where there are relatively few EM trained
staff, few or no EM training programs, and limited organization of emergency medicine
services. Further increasing the burden on weak EM services in these health-care settings
is the frequent lack of access to primary care, leading many patients to seek delayed
treatment, often in an acute or critical state. As a result, resource-limited settings
experience a significant mismatch of needs and services: high rates of critically
ill patients and constrained or underdeveloped EM systems. The need for EM services
in such settings is clear, yet to date efforts toward establishing EM in resource-limited
settings have been slow. In Ethiopia, initiatives are supported by the Ministry of
Health to increase emergency medicine capacity, and in particular the number of trained
EM professionals. Ethiopia, like much of the region, continues to suffer from an ongoing
‘brain drain’ [1], with many Ethiopian-trained physicians pursuing specialty-training and employment
abroad. As part of an effort to combat this, in 2010 Addis Ababa University initiated
the first emergency medicine residency training program at Tikur Anbessa Hospital.
The first cohorts have entered a 3-year training program and are expected to become
the next generation of teachers and leaders of EM in Ethiopia. As part of a group
of emergency medicine physicians and residents at the University of Toronto, we have
been collaborating in the above-mentioned endeavor.

Importance

To inform the effort at Addis Ababa University in the establishment of Ethiopia’s
first EM residency training program, we conducted a systematic review of the published
literature on emergency medicine training programs in resource-limited health-care
settings. We focus on low- and middle-income countries (LMICs) in particular, given
the unique challenges facing resource-constrained settings in developing EM as compared
to high-income countries. These challenges include: limited access to health care
for the general population, limited resources within the health-care system, as well
as an emerging double burden of both communicable and non-communicable diseases [2].

Goals

To our knowledge, to date there has been no such review, and we aim to provide a useful
resource for other LMICs interested in developing EM residency training programs,
as well as for those interested in collaborating with these groups.

Methods

Search strategy

We searched the following electronic databases for relevant articles, without restriction
to language, participant age or study design:

The literature search was conducted using the following search terms: Emergency Medicine,
Emergency Medicine Services, Education, Training, Residency Programs, Emergency Medical
Systems and Medical Education. The results were then limited to low, low-middle, and
upper-middle income, excluding high-income countries based on the World Bank World
Trade Indicators classification 2009-2010 – [3]. The full search strategy for each of the databases may be obtained from the authors
upon request. As an example, the full EMBASE search strategy is demonstrated in Additional
file 1. A search of the gray literature was not undertaken as one of our goals was to identify
gaps in currently published literature in this area potentially resulting in recommendations
for future publications.

Inclusion/exclusion criteria

(2) Programs focused on training physicians or physician trainees at any level, from
medical student to continuing medical education modules (CMEs). (Given that many resource-poor
countries complete GP training first and often work for a period of time before returning
for specialty training, CMEs were included, to avoid excluding a significant group
of trainees)

(3) Described training programs in low- and/or middle-income countries. The search
initially included only low- and low-middle-income countries, but was later extended
to include all middle-income countries, given the similar lessons in and challenges
of attempting to establish EM training programs in many of these settings.

Exclusion criteria were as follows:

(1) Articles reporting a case report or series

(2) Articles representing a general topic review, with the exception of reviews of
EM training programs

(3) Articles reporting training programs for non-physicians.

In addition, the search resulted in a large number of articles on specific topics
of potential relevance to EM, including: disaster preparedness and/or complex humanitarian
responses, emergency obstetrics and emergency contraception and toxicology. As many
of these were general topic reviews, they were excluded unless they described a course
or training program designed for or part of an emergency medicine training program
for physicians.

Selection process

Studies were selected as described below. The selection process consisted of three
steps: a title review, abstract review and full article review. Articles were independently
reviewed by three reviewers at each stage, with final selection for inclusion at each
stage based on discussion and group consensus. The search returned 5,045 titles. After
the removal of duplicates, 3,765 titles were reviewed, from which 258 abstracts were
chosen for review and 96 chosen for full article review. As we were unable to obtain
the full text of 1 article [4], 95 articles were reviewed in full, with 16 meeting the full inclusion criteria (see
Figure 1).

Findings are summarized below, in narrative form, under the headings: ‘General program
details’, ‘Curriculum’, ‘International partnerships and exchanges’ and ‘Graduate retention’.
Table 1 provides a summary of the EM training program details available from the 16 articles.
Table 2 provides a summary of the Results section.

General program details

The majority of articles indicate there is only one EM program per country, with programs
ranging in size from 3 to 30 trainees per year, and total graduates to date varying
widely from 8 to 250. Training programs are structured in three main ways: 1-2-year
fellowship programs for general physicians, 2-5-year programs with direct entry into
EM residency after medical school and 4-6-year master’s degree programs.

Curriculum

Globally, there are many variations of EM systems and EM training models, but traditionally
EM training and practice have been in either of two main system models. The first
is the Anglo-American system with skilled Emergency Department (ED) physicians and
pre-hospital emergency medical services utilizing paramedics. The second is the Franco-German
system, with a highly developed pre-hospital emergency physician service, but only
a basic organization of hospital-based emergency medicine [5]. Since the roles and responsibilities of emergency physicians in these systems differ
substantially because of the larger impact of the prehospital care in the Franco-German
model, the training needs may differ to some degree as well. Moreover, the Franco-German
model of EM systems tends to triage emergencies to particular subspecialty areas upon
arrival to the hospital (orthopedics, general surgery, obstetrics/gynecology, etc.),
and therefore ED physicians in such systems are not exposed to nor require training
in many subspecialty emergencies. As a result, the EM training needs in this system
may differ substantially from the training received in the Anglo-American EM system,
which provides care for a broader scope of emergencies.

Seven countries report modeling of their curriculum after established EM systems and/or
training programs. The Bosnian curriculum is modeled specifically after the Society
for Academic Emergency Medicine core curriculum [6], though the article doesn’t mention whether this was modified in any way for the
local context. Turkey and Brazil also chose to adapt the mature and tested North American
(NA) EM training model [7]. Both the Turkish and Brazilian curricula underwent many modifications to better
suit the local health-care needs [8]. Similarly, the Costa Rican curriculum was developed after studying a large number
of formats from NA that were then adapted to the Costa Rican context [9].

Of the remaining three articles providing information on curriculum modeling, only
the one in Cameroon is influenced by the significantly pre-hospital care-based French
EM system [10]. Finally, in China and Armenia the curricula were fostered to specifically address
local needs with input from US partners, but neither seemed to adopt a specific EM
model [11,12]. The remaining articles do not discuss modeling after any particular curriculum or
EM system.

In terms of curriculum specifics, only nine of the articles describe the components
of the EM residency curriculum to some degree. The majority simply outlines the duration
of training, seven list rotations (rarely with duration), and six describe extracurricular
activities such as standardized advanced life support/trauma courses. Four comment
on research activities and journal clubs (see Table 1).

The recently published International Federation for Emergency Medicine (IFEM) Model
Curriculum for Emergency Specialists [13] is intended to provide standard, globally recognized guidelines for educational programs
in emergency medicine. Depending on local resources, the implementation of these guidelines
will be variable. Though the training structure or content are not explicit, the IFEM
model provides a summary of the core training requirements of well-established existing
training programs. It makes the following recommendations: that a program take place
in an appropriate clinical setting, with adequate resources for best practice, supervision
of trainees, ongoing evaluation and feedback and a list of core competencies for each
year of training. The recommended overall duration of training should be at least
3 years, including training in critical care, surgery and subspecialties, internal
medicine, pediatrics, prehospital/disaster medicine and emergency medicine as well
as, a component of scholarly activity or research. We indicate consistency with the
IFEM model where sufficient curriculum details were provided (see Table 1).

International partnerships and exchanges

Eleven articles discussed international partnerships and exchanges as an important
component of the process of developing an EM training program. The nature and extent
of these partnerships varied from country to country.

In Bosnia, there was an in-country training program for emergency MDs in partnership
with the International Medical Corps (IMC) Emergency Medicine Training Project at
Zenica Regional Hospital. This partnership consisted of American board-certified MDs
training Bosnian physicians with daily educational activities, weekly didactic sessions
and clinical bedside supervision [6].

In Jordan, initial EM training courses were developed in consultation with an American
emergency physician [14]. Subsequently, three Jordanian physicians and three nurses from the initial training
group spent 3 months at Brooke Army Medical Center in the USA where they participated
in a clinical and didactic experience in the ED and ICU. More recently, after completing
the domestic 7-year program, family physicians undertaking EM specialty training have
been sent to either the UK (Royal Infirmary of Edinburgh or University Hospital London)
or the US (Pennsylvania State University) for a 1-year fellowship. During this time,
they receive once-weekly didactic sessions as well as complete practical training
modules.

Armenia developed a collaborative effort between the Boston University Medical Center,
the University of Massachusetts Medical Center, the Armenian Ministry of Health and
the Emergency Hospital of Yerevan, Armenia. A program director and assistant with
previous EM experience and training in the USA were appointed to lead the initial
efforts. The collaboration led to the development of an EM curriculum translated into
Armenian and Russian and ongoing exchanges between the Armenian Emergency Hospital
and partner hospitals [12].

Cameroon, which partnered with the Mission d’Aide et de Coopération française au Cameroun, provided trainees with a 2-month internship with the emergency medical services in
France. As part of their internship, they also received first-aid training and certification
as first-aid instructors [10].

In China, EM development has been ongoing with international partners providing in-country
training. Three American emergency physicians and two nurse managers offered consultation
and intermittent teaching and administrative support for a total of 7 months over
the span of 2 years at Sir Run Run Shaw Hospital in the Zhejiang Province. Their goals
included observation, identification and development of a basic framework of emergency
care at this hospital [11].

Papua New Guinea has had an ongoing collaboration with Australian physicians through
the Australian Agency for International Development (AusAID). AusAID initially supported
an emergency physician in residence in Papua New Guinea and 14-day visits from seven
other EM physicians as a limited project. Following this initial project, the University
of Papua New Guinea established a Senior Lecturer position in Emergency Medicine,
with several US emergency physicians rotating through since [15,16].

In Malaysia, a master’s degree in Emergency Medicine was initiated in 1986 in collaboration
with the University of Sydney. In an effort to ensure that the EM training program
at the University Sains Malaysia maintains international standards, they have been
networking with international EM bodies and practitioners including participation
of international EM professionals in the annual professional examinations as external
examiners [17].

Costa Rica had two stages of collaboration with American physicians [9]. Initially, an American EM physician provided in-country training to 21 local faculty
members who would subsequently train the local residents. In the second stage, a regionally
appropriate curriculum was developed by a core group of Costa Rican physician educators
with assistance from American emergency medicine specialists. Costa Rica has also
partnered with several Latin American countries to provide exchanges to benefit from
local knowledge and experience by sharing best practices as applied in their region.
The authors note that the initial stage of this collaboration, which focused on local
faculty preparation for the residency program, was key to the program’s ultimate success.

In Peru, residents spend 1 month in either Colombia or the US for exposure to organized
trauma systems during the course of their training. The Peruvian Society of Emergency
Medicine and Disasters (SPMED) was established in partnership with Colombia and the
USA, and it further emphasized collaboration with international EM organizations by
forming the Latin-American Association of Cooperation in Medical Emergencies and Disasters
[18].

The article on South African EM training only notes that South African EM residents’
diplomas receive reciprocity with the Fellowship in Immediate Medical Care of the
Royal College of Surgeons in Edinburgh; however, no details of what this entails are
provided [19]. No partnerships or exchanges are mentioned in the articles on Turkey, Cuba and Brazil
[7,8,20,21].

Graduate retention

Despite the hope that developing quality EM training in-country may help to combat
the loss of physicians who leave to undertake such training elsewhere, few articles
provide information on graduate retention. While Costa Rica, Peru, South Africa, Turkey
and Malaysia report graduate retention rates to be rather high [9,17-20], the experience in Papua New Guinea is quite different; many trainees leave to work
in New Zealand or Australia where the financial reimbursement and work conditions
are reported to be superior [15,16].

Discussion

To our knowledge, this is the first review of this type and as such provides some
insight into the experiences of various resource-limited health-care systems in initiating
EM training programs. Common among the majority of the new programs was the adaptation
of components of well-established EM program curricula, principally those of HICs
and Anglo-American EM systems, as a foundation for their own curriculum development.
With the continued success of these well-established EM training programs over the
last few decades, these curricula may be viewed as a reliable base. However, given
the unique challenges facing many resource-limited health-care systems, adaptation
to ensure training is matched with local needs, priorities and resources would seem
prudent if not essential to the success of a developing EM system. Several but not
all articles reported on such forms of adaptation to the local context.

The second finding, common to most of the reported programs, is the development of
international partnerships, with or without exchanges between participating programs.
Akin to basing curriculum development on proven models, partnerships and exchanges
allow participants from developing EM programs to observe and/or experience best practices
modeled by mature EM programs and to benefit from clinical and didactic teaching from
established EM practitioners. In the initial stages of EM development, local clinical
EM expertise may be lacking. Therefore, partnerships benefit both the first cohorts
of trainees as well as the pioneering local faculty who typically come from specialized
clinical backgrounds such as surgery, anesthesia or internal medicine. Nonetheless,
while much can be learned from partners from mature EM system, as these are predominantly
from HICs they may not have much in common with LMIC health systems (even if taking
into account lessons learned at the time of initial EM development in HICs). Therefore,
partnerships to share experiences among similar health systems, such as the Latin-American
partnerships reported above, would seem of added benefit and worthy of further exploration.

In contrast to the apparent benefits of partnerships, the advantages of exchanges
appear to be less clear with some programs suggesting they may contribute to ‘brain
drain’ [15]. Given that relatively few articles have reported on graduate retention, information
is lacking as to under what circumstances and to what extent exchanges contribute
to the loss of EM physicians after training. The burden of physician migration on
already strained LMIC health systems and implications of the ‘brain drain’ phenomenon
on the continuity of EM training programs in these systems necessitate efforts to
monitor and share information regarding graduate retention.

Going forward, it would be useful to attempt to fill the current gaps in the literature
by encouraging further knowledge and experience exchange. This could be attempted
through focused surveys of newly established EM programs and/or development of a standardized
format for reporting on the successes and pitfalls in curriculum development, international
partnerships/exchanges as well as attempts at thwarting brain drain and encouraging
graduate retention.

Limitations

Despite the breadth of our search, relatively few articles met all of the inclusion
criteria, with the majority reporting the experiences of UMICs in establishing EM
programs. As noted by Arnold, “the successful development of EM relies on a reasonably
mature healthcare system, with development of not only a specialty for physicians
but also pre-hospital services, emergency departments well-integrated into the hospital
system, as well as, specialized nursing care” [22]. The paucity of literature from LMICs may reflect the relative lack of preparedness
of LMIC health systems for the development and practice of EM, particularly with respect
to lack of infrastructure, facilities, equipment and supplies. While the UMICs’ experience
is not directly applicable to the LMIC setting, it may still provide useful building
blocks for the development of EM when appropriately adapted. Such reports also provide
information helpful to LMIC governments by providing insight into priorities for investment
including both training and systems components that are essential to the development
and provision of emergency care. Finally, although we are aware of several newly developed
EM programs in Ghana, Tanzania and Botswana, as these are not yet described in the
published literature, a search of the gray literature or contacting these programs
directly may allow for a broader description of EM development in LMICs in the future.

The majority of programs reported in the included articles are in their infancy (<5
years) and, with the exception of the Turkish programs, updates on development of
the programs since the articles were originally published were not provided. As a
result, this review is limited in its ability to determine what specific aspects might
result in longer-term success or failure of LMIC EM programs. More information from
the individual programs would be necessary to determine this and will hopefully become
available as more programs provide updates as they continue to grow and evolve. In
addition, while some articles provide detailed descriptions of their training programs,
many provide only a brief general overview, which further limits the ability to draw
conclusions as to what aspects of the programs reported have contributed most or might
be considered essential to the successful development of EM in these settings.

Conclusions

The results of our search indicate that EM training is in its infancy in LMICs. There
are few reports of these programs’ successes and limitations, including efforts to
optimize graduate retention. The paucity of published literature on EM training in
LMICs likely reflects the resource constraints, with the development of the specialty
of EM closely tied to that of the entire health-care system. We encourage developing
EM training programs in LMICs to continue reporting on their efforts, whether successful
or not, in order to help gain further understanding of the facilitators and roadblocks
to such efforts. It would be helpful to gain further insight into the details of these
programs including the duration, format and curriculum details including the individual
rotations, number of hours, and even specific goals and objectives for each rotation.
Considering the recent publication of the IFEM residency curriculum recommendations,
we would encourage reporting based on these recommendations. Furthermore, we feel
it is crucial to provide detailed reporting on graduate retention efforts as well
as any reasons for ongoing “brain drain” in a given setting; this may identify modifiable
causes for loss of trained specialists that could aid the development of preventative
efforts in this area in newly developing programs. Moreover, it would be helpful to
know what other educational activities and extracurricular activities are taking place
within each EM training program and which of these efforts are feasible at a given
stage of EM residency program development; this may include local conferences and
research efforts, as well as CME opportunities. We also commend and encourage early
development of collaborations and knowledge exchange with other geographically proximal
programs such as the Latin-American Association of Cooperation in Medical Emergencies
and Disasters in South America. These may be in the form of exchanges of trainees/fellows
for short periods of time, collaborative research or regional conferences and formation
of regional EM societies to help strengthen EM as a specialty in a given region. Finally,
we want to underline the importance of publishing the above information in open access
journals as this will make very relevant information readily available to groups entertaining
the idea of developing EM training programs in low-resource settings.

Abbreviations

Competing interests

Megan Landes is supported by a New Investigator Award from the Department of Family
and Community Medicine, University of Toronto. The authors report no conflicts of
interest.

Authors’ contributions

All authors participated in the conception and design of the study. AN, ML and LPR
independently reviewed the articles. LPR provided methodological oversight. AN and
LPR drafted the manuscript. All authors participated in critical revisions of the
manuscript, read and approved the final manuscript. AN takes responsibility for the
integrity of the paper as a whole.

Acknowledgements

The authors acknowledge Dr. Donald A. Landes, PhD, for his help with article translation.